Unknown Individual – Psychiatry Physician, NPI 1609866854
Excluded from federal healthcare programs (Medicare/Medicaid)
This provider is listed on the OIG List of Excluded Individuals/Entities (LEIE). Exclusion effective: 2024-09-19. Reason: Felony conviction relating to controlled substance (mandatory; min. 5 years).
Psychiatry Physician
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Doctor Profile
Profile Insights
NPPES metrics only — not quality of care.
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Provider Addresses for Unknown Individual
2640, West Point Road, Green Bay, Brown County, Wisconsin, 54304, United States
GREEN BAY, WI 543041344
Phone: (920) 869-2711
Type: Location
365, Steuben Road, Town of Deerfield, Oneida County, New York, 13431, United States
ONEIDA, WI 541550365
Phone: (920) 869-2711
Type: Mailing
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
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Medicare Enrollment & Revalidation
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No Medicare enrollment or revalidation data available for this provider in our database.
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Medicare Utilization (FFS)
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No Medicare fee-for-service utilization data available for this provider in our database.
Insurance plans in this area (ZIP 54304)
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Provider's Procedures
| Specialty | Practice State | HCPCS Code | Description | Service Count | Beneficiary Count |
|---|---|---|---|---|---|
| PSYCHIATRY | WI | 90792 | Psychiatric diagnostic evaluation with medical services | 19 | 19 |
Group practice members
| Name | Specialty | State |
|---|---|---|
| Clinical Social Worker | WI | |
| Nurse Practitioner | WI | |
| - | WI |
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